benigh prostatic hyperplasia

BENIGN PROSTATIC HYPERPLASIA

DR. FRANCISCO N. ESTANISLAO JR.

General Objectives:

1) To present a case of benign prostate hyperplasia

2) To discuss the cause, symptoms and guideline of treatment of the disease

Specific objective:

1) To present a combination drug therapy for the disease

Patient’s Profile:

•P.L , 66 y.o male•married, Filipino, Roman Catholic farmer, residing at Consolacion, Cebu

Chief complaint :• Dysuria

•hypertensive for(5) years as claimed

highest BP of 150/100; usual BP 120/70

•herbal medications

• non diabetic, non asthmatic.

•HFD : (+) HPN

•Non smoker ; Occasional alcoholic drinker

•No allergies to food and drugs

•No previous hospitalization

Past Medical History:

I month PTA – noted to have dribbling and decrease in stream upon urination with occasional urinary frequency. Condition just tolerated. Took herbal medications with some relief. No consults done.

History of Present Illness:

5 days PTA - complained of lumbar pain radiating to the hypogastric area associated with urinary frequency. No fever. No meds taken.

History Of Present Illness

4 days PTA - sought consult with AP and prescribed with Paracetamol+Ibuprofen 1 tab 3x a day, Co Amoxiclav 625 mg 1 tab 3x a day with good compliance which afforded some relief.

History of present illness

Morning PTA – persistence of symptoms with dysuria thus sought consult and subsequently

admitted

History of present illness

Physical examinationExamined pt. conscious, coherent, afebrile NIRD:

Bp – 110/70 HR – 89 RR – 21 Temp 36.8

Skin: senile turgor , no lesions

HEENT: anicteric sclerae, pinkish palpebral conjunctiva

C/L: ECE, clear breath sounds

CVS: DHS, (-) murmur

Abd: NABS, soft, no mass, no tenderness

GUT: (-) KPS bilateral

Ext: strong pulses

CNS: no neurologic deficit

Rectal: tight sphincteric tone, no mass, no rectal wall tenderness

Prostate- smooth , firm, elastic, non tender, enlarged

Differential Dx :

•Cystolithiasis

•Acute prostatitis

•Neurogenic bladder

Impression: R/I Benign Prostatic Hyperplasia ; Urinary tract infection

Venoclysis started w/ PNSS 1L at 20 gtts / min

Started w/ Co Amoxiclav 1.2 g slow IVTT q 12

Referred to a urologist for consult

Labs were taken

At the E.R

CBC

WBC 19.76

Neu 88

lymp 10

mono 2

HCT 36.2

HGB 12.5

PLT 251

On admission:U/A

Color Straw

pH 6.0

Sp. gr 1.010

Gluc neg

Protein

neg

Rbc 0-2

Wbc 0-2

Ec rare

Crea 6.53

BUN 70

Na 124

K 4.31

Ca 1.04

UTZ KUB

Obstructive Uropathy bilateral, etiology undetermined. Suggest IVPUrinary bladder – negativeNormal prostate gland (2.8 x 4.0 x 2.2 cm) volume 13.8 ml. Outline is smooth.

Chest xray : no significant findings

S : (+) urinary frequency, (+) dysuria, (-) fever

O: Abd: NABS, soft, no tenderness, distended bladder

A: Azotemia sec to Bladder Outlet obstruction

probably sec to BPH

P: FBC was inserted; initial drain 1.2L

NaCL 1 tablet TID

Co- amoxiclav 600 mg IVTT q 12

Course in the ward:Day 1

Repeat creatinine, HBAIC, Lipid profile, Uric acid

Urologic notes:

Azotemia sec to Bladder outlet obstruction sec to contracted bladder or high lying prostate gland

Recommendation: Cystoscopy - TURP

S: (-) urinary frequency, (-) fever

O: Bp – 100-120/70 Hr – 75-80 RR – 20 Temp- 36.5

Abd: NABS, soft, (-) tenderness

Urine output: 75cc / hr

Labs: Creatinine - 3.63 Uric acid – 8.7

HbAIC – 5.6

Lipid panel: Gluc- 112.10 LDL- 74

Chol – 125.87 Trig – 80.19

Day 2

A : Resolving Azotemia ; BPH ; Hyperuricemia

P: C0 Amoxiclav 600 mg IVTT q 12

Allopurinol 100mg 1 tab OD

NacL 1 tablet TID

S : no subjective complaints, (-) fever

O:

C/L : ECE, CBS

CVS : DHS , (-) murmur

Abd : NABS, soft, (-) tenderness

Urine output : 145 cc/ hr

Day 3

BP 110-130/70-80

HR 68 – 75 bpm

RR 19 – 20 cpm

Temp 36.5 – 36.8

Labs :

Creatinine – 1.86

A : Resolving Azotemia ; BPH ; Hyperuricemia

P : Co amoxiclav 1.2 g IVTT q 12

Dutasteride + Tamsulosin 500/4oomcg 1 cap OD

Allopurinol 100 mg 1 tab OD

For repeat creatinine

S : no subjective complaints, (-) fever

O :

C/L: ECE, CBS

CVS: DHS, (-) murmur

Abd: NABS, soft, (-) tenderness

Urine output : 139cc / hr

Day 4

BP 110-130/60-70

HR 75 – 80 bpm

RR 19 -21 cpm

Temp 36.6 – 36.8

Labs :

Creatinine: 1.43

Meds: Co amoxiclav 1.2 g IVTT q 12

Allopurinol 100 mg 1 tab OD

Dutasteride + Tamsulosin 1 tab OD

A : Azotemia resolved; BPH ; Hyperuricemia

P : Co amoxiclav 625 mg 1 tab BID p.o

Referred back to urologist for co management

S : no subjective complaints, (-) fever

O :

C/L : ECE, CBS

Abd: NABS, soft, (-) tenderness

Urine output : 14occ / hr

Day 5

BP 120/80

HR 75-80

RR 20

Temp 36.5 – 36.8

Meds: Co- amoxiclav 625 mg BID p.o

Dutasteride + Tamsulosin 1 tab OD

Allopurinol 1oomg 1 tab OD

A : Azotemia resolved ; BPH ; Hyperuricemia

P: Scheduled for Cysto – TURP

Referred to a cardiologist for CP clearance

Referred to anesthesiologist for anesthesia

For APTT, BT, Blood typing, Protime, Na, K

ECG 12 leads

S : (-) fever , good appetite, (+) BM

O :

C/L : ECE, CBS

CVS : DHS, (-) murmur

Abd: NABS, soft , (-) tenderness

Urine output : 12occ / hr

Day 6

BP 12o/70

HR 78 - 82

RR 20

Temp 36.5 – 36.7

Labs :

Protime – control 13.0, patient 12.8

103% activity, INR- .99

APTT – control 31.5, patient 31.9

BT – 1 min Blood type- A+

Na – 139 K- 3.56

ECG – sinus bradycardia w/ left atrial abnormality, non specific ST-T wave changes

Meds: Co amoxiclav 1 tab BID p.o

Dutasteride + Tamsulosin 1 tab OD p.o

Allopurinol 100mg 1 tab OD

A : BPH ; Hyperuricemia

P: CP cleared by cardiologist

Seen by anesthesiologist w/ pre op orders

NPO post midnight ; Bowel prep

Omeprazole 40mg IVTT x 1 dose at bedtime

S: (-) fever ; (+) hematuria

O :

C/L: ECE, CBS

CVS: DHS, (-)murmur

Urine output : 86cc / hr

Day 7 ; Post Op D 1

BP 130-140/70-80

HR 82-86

RR 19-22

Temp 36.4-36.7

Meds: Co amoxiclav 625 1 tab BID p.o

Dutasteride + Tamsulosin 1 tab OD

Allopurinol 1oo mg 1 tab OD

Tramadol 25 mg slow IVTT q 6 prn for pain

A : S/P Cysto-TURP ; Evacuation of bladder stone ;

BPH

P: Cystoclysis at moderate fast drip then decrease rate if with no more hematuria

> 15 grams of prostatic tissue were evacuated

Presence of urinary bladder stone < 2mm was evacuated

Intraoperative findings:

S : (-) fever ; (-) hematuria ; (-) BM

O:

C/L: ECE, CBS

CVS: DHS, (-) murmur

Abd: NABS , soft , (-)tenderness

Urine output : 55 cc / hr

Day 8 : Post op Day 2

BP 110-130/70-80

HR 78-84

RR 19-20

Temp 36.5-36.7

Meds:

Co- amoxiclav 625 mg 1 tab BID

Allopurinol 100 mg 1 tab OD

Dutasteride + Tamsulosin 1 tab OD

Tramadol 50 mg 1 tab TID prn for pain

A: BPH ; S/P Cysto TURP ; Evacuation of bladder

stone

P: IVF was consumed and terminated

S : (-) hematuria ; (-) fever, (-) BM

O :

C/L : ECE , CBS

CVS: DHS, (-) murmur

Abd: NABS, soft, (-) tenderness

Urine output : 96cc / hr

Day 9 ; Post op D3

BP 120/70

HR 75-80

RR 20

Temp 36.4-36.7

Meds : Co Amoxiclav 625 1 tab BID

Allopurinol 100 mg 1 tab OD

Dutasteride + Tamsulosin 1 tab OD

A: BPH ; S/P Cysto – TURP ; Evacuation of bladder stone

P: Cystoclysis was discontinued

FBC removed

• Able to void freely

• Discharged, improved

Final Dx :

Azotemia sec to Bladder Outlet Obstruction sec to BPH; Cystolithiasis S/P Cysto-TURP ; Evacuation of bladder stone

Biopsy : Nodular Hyperplasia ; Chronic prostatitis

Day 9 ; Post op D4

Most common disorder of the prostate gland

Proliferation of smooth muscles and epithelial cells

Normal aging process

May affect the quality of life

Cannot be prevented

Can be “treated”

Benign Prostate Hyperplasia

Anatomy

Name Fraction of gland Description

Peripheral zone (PZ)Up to 70% in young men

It is from this portion of the gland that ~70-80% of prostatic cancers originate.[14][15]

Central zone (CZ)Approximately 25% normally

This zone surrounds the ejaculatory ducts.

Transition zone (TZ) 5% at puberty

The transition zone surrounds the proximal urethra and is the region of the prostate gland that grows throughout life and is responsible for the disease of benign prostatic enlargement

Anterior fibro-muscular zone (or stroma)

Approximately 5%

This zone is usually devoid of glandular components, and composed only, as its name suggests, of muscle and fibrous tissue.

Peripheral zone

Transition zone

Urethra

Anterior lobe -roughly corresponds to part of transitional zone

Posterior lobe -roughly corresponds to peripheral zone

Lateral lobes - spans all zones

Median lobe -roughly corresponds to part of central zone

Lobes

Aging males

Fifth decade of life – 50% evidence of BPH

Increase in growth .5 - .8 g / year

80 years old – 90% evidence of BPH

Epidemiology :

Hyperplasia of stromal and epithelial cells causing enlargement of the gland

Dihydrotestosterone – mediator of prostate growth

A-1 adrenergic receptors on the smooth muscles of the stroma, capsule of the gland and bladder neck

Pathophysiology:

Serum testosterone

5 alpha- reductase

Serum Dihydrotestosterone

DHT – androgen receptor complex

Growth factors

Increased cell growth

Peripheral zone

Transition zone

Urethra

CausesCauses::

1)Static component – direct bladder outlet obstruction from the enlarged gland

2)Dynamic component – increased smooth muscle tone and resistance within the enlarged gland

Lower Urinary tract Syndrome

Voiding (obstructive) symptoms:

Weak urinary stream – common symptom of BPH

Prolonged voiding – linked to weak urinary stream and frequently accompanied by straining of abdominal muscles upon urination

Hesitancy – a delay between the voluntary attempt to void and the actual initiation of urination

Intermittency – involuntary disruption of the urinary stream during voiding

Incomplete emptying – may be accompanied by the continued desire to void or by pain or discomfort in the bladder area

Terminal dribbling – inability to effectively terminate voiding

Storage (irritative) symptoms:

Urinary frequency – associated with bladder irritation that presents as a need to void repeatedly during the day.

Nocturia – the need to void during sleeping hours more than once

Urgency – the need to urinate immediately

Urinary incontinence – involuntary loss of urine.

Complications:

Acute urinary retention

Renal insufficiency

Recurrent urinary tract infections

Gross hematuria

Bladder stones

History and Physical examination

Symptoms assessment

International Prostate Symptom Score Questionnaire

Diagnosis of BPH :

UrgencyOver the last month, how difficult have you found it to postpone urination?

0 1 2 3 4 5

Weak streamOver the past month, how often have you had a weak urinary stream?

0 1 2 3 4 5

StrainingOver the past month, how often have you had to push or strain to begin urination?

0 1 2 3 4 5

Mildly symptomatic : 0-7

Moderately symptomatic : 8-19

Severely symptomatic : 20-35

IPSS score :

Detects size , consistency , contour

Screening exam for prostate CA

Sphincteric tone – rule out neurologic disease

Digital Rectal Exam:

Urinary bladder – stones ; tumors ; post residual volume ;

Kidneys – size ; stones

Prostate – size ; volume ; calcifications

Ultrasound :

Urinalysis

Prostate Specific Antigen – to rule out prostatic adenocarcinoma

Serum creatinine (optional)

Laboratory :

A. Watchful waiting / Active surveillance

- mild symptoms of LUTS (IPSS score < 8)

- moderate-severe symptoms of LUTS

(IPSS score >8)

- not bothered by their symptoms

Management (AUA guidelines)

Behavioral Modifications:

- reduction of fluid intake (especially at bedtime)

- moderation of alcohol and caffeine intake

- use of time voiding schedules

- discontinuation of drugs that can aggravate

bladder or outlet obstruction

e.g. anhistamines , decongestants

B. Medical management

- moderate-severe symptoms of LUTS

(IPSS score >8)

- bothered by symptoms

C. Surgical intervention

- moderate-severe symptoms of LUTS

(IPSS score >8)

- bothered by symptoms

- affect the quality of life

- complications of BPH

- failed medical therapy

- patient’s choice

Acute urinary retention

Bladder stones

Upper urinary tract dilatation

Renal failure

Absolute indications for surgery

Hematuria

Large post voidal residuals

Recurrent urinary tract infections

Relative Indications:

Benign prostate hyperplasia

Enlarged Normal Enlarged Enlarged

Prostate Prostate Prostate Prostate

Mild sx Mild-Mod Mod- Sev Mod-Sev

No bother Bother Bother Acute Urinary

Retention

Watchful A- blockers Comb Tx Catheterization

Waiting Comb tx

Modifications

Tx failed Trial voiding

Failed

Min Invasive procedure

Surgery

A. Alpha blockers

Non selective and selective alpha 1- adrenergic

receptor blockade

Relieves lower urinary tract symptoms by:

- relaxation of smooth muscle tone in prostatic

stroma and bladder neck

- relaxation of bladder smooth muscle

- central action

Medical therapy

Non selective alpha blockers:

1)Phenoxybenzamine

Selective short acting alpha 1 blockers:

1)Alfuzosin 2.5 mg, 10 mg – no anejaculation

2)Prazosin

Selective long acting alpha 1 blockers:

1)Terazosin 1 mg, 2 mg, 5 mg – dose dependent

2)Doxazosin 4 mg, 8 mg – dose dependent

Partially subtype ( alpha-1a) selective agents

1)Tamsulosin 200 mcg, 400 mcg – uroselective

2)Silodozin – new drug

Postural Hypotension – most common

- dizziness

nasal congestion

Headache

Ejaculatory dysfunction

Side effects:

Intraoperative Floppy Iris Syndrome

-Triad of progressive intra op miosis, billowing of a flaccid iris and iris prolapse toward the incision site during phacoemulsification for cataracts

-Common in tamsulosin : 43%-90%

Caution:

Inhibition of DHT receptor complex formationProfound decrease in the concentration of DHTDecrease in prostate size

1)Dutasteride 500 mcg2)Finasteride 5mg – refractory hematuria sec to prostatic bleeding

5 a- reductase enzyme inhibitor

Decrease libido

Erectile dysfunction

Ejaculation disorder

Adverse effects:

Widely used for treatment of various ailments

Readily available

cheaper

Less adverse effects

Phytotherapy

Saw palmetto berries – American dwarf palm

Antiandrogenic effect

Inhibition of 5 a reductase enzyme

Anti inflammatory

Improve subjective complaints

Dosage : 160 mg twice a day

Adverse effects : G.I discomfort

American Urologic Association

- Available data do not suggest that saw palmetto has clinical meaningful effect on LUTS sec to BPH.

- Further clinical trials are still in progress

Recommendation:

- No dietary supplement, phytotherapeutic agent or other non conventional therapy is recommended for the management of LUTS sec to BPH

Alpha blockers + 5a reductase enzyme inhibitor

Finasteride + Doxasozin

Dutasteride + Tamsulosin

Medical Therapy of Prostate Symptoms (MTOPS)

large scale, long term study with a recruitement of 3047 men with BPH and a mean follow-up of 4.5 years.

Combination therapy

Found that combination therapy with alpha 1 blocker and 5 a- reductase inhibitor provided benefits over either drug as monotherapy in terms of reduction in the risk of clinical progression

Key Findings:

Decreased risk of progression

- a- blockers – 39%

- 5 a- reductase inhibitor – 34%

- Combination therapy – 66%

Decrease risk of acute urinary retention

- combination therapy - 81%

- 5 a- reductase inhibitor – 68%

- a- blockers – 35%

Decrease in prostate volumes

- greatest reduction in combination therapy and 5 a reductase inhibitor

Adverse effects :

None of the adverse effects occurred with a frequency of > 6 events per 1oo patient-years on follow-up

Discontinuation rates is lesser on combination therapy (18%) than in a- blockers (27%) and 5-a reductase inhibitor (24%)

Conclusion:

Combination therapy has been shown to provide fast symptom relief, reduced prostate growth, reduced risk of acute urinary retention and the need for BPH related surgery

Combination of Avodart and Tamsulosin trial (CombAT) study

-66% reduction in the risk of acute urinary retention and BPH related surgery

-44% decrease in clinical progression of the disease

Transurethral resection of the Prostate

Gold standard for obstructive BPH

Standard of care when all other methods fail

Surgery

Surgical removal of the prostate’s inner portion through endoscopic approach through the urethra under general / spinal anesthesia

Indications:

a) refractory urinary retention

b)Renal insufficiency sec to bladder outlet obstruction

c)Recurrent UTI

d)Recurrent gross hematuria

e) Bladder calculi

f) Permanently weakened or damaged bladder

Complications:

a)TUR syndrome – dilutional hyponatremia

b)Hematuria

c)Erectile dysfunction

d)Bladder neck contracuture

e)Irritative voiding symptoms

Open Prostatectomy

Surgical removal of the prostate via suprapubic or retropubic incision in the lower abdominal area

Indicated in very large prostate

Prostate volume of 80-100 ml

a) Significant risk of blood loss

b) Need for blood transfusion

c) Erectile dysfunction

d) Retrograde ejaculation

e) Longer hospital stay compared to TURP

Complications

1) Transurethral needle ablation of the prostate

2) Transurethral microwave thermotherapy

3) Transurethral Holmium laser ablation

4) Transurethral Holmium laser enucleation

5) Transurethral vaporization

6) Photoselective vaporization

7) Transurethral incision of the prostate

Minimal invasive procedures

Thank you!